Document Type : Original Article


1 Department of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran,

2 Department of Nursing, Faculty of Medical Sciences, University of Tarbiat Modares, Tehran, Iran


BACKGROUND: Discrimination in health care is a common phenomenon whose complete
understanding has always been a major concern of health-care systems to control and reduce it.
This study aimed to explore the experiences of unintentional discrimination and related factors in
health-care providers.
MATERIALS AND METHODS: This qualitative study was conducted with a content analysis approach
in 2019. Data were collected through semi-structured interviews with 13 health-care providers including
two physicians, three nursing supervisors, two head nurses, four staff nurses, and two nurse aides
in two general hospitals in Tehran, Iran. Participants were selected through purposeful sampling.
The obtained data were analyzed by Graneheim and Lundman method.
RESULTS: Three main categories and eight subcategories were obtained from the data
analysis: (1) forced discrimination (superiors’ pressures and executive orders, occupational concerns,
and fear of the superiors); (2) guided discrimination (professional challenges, managers’ policymaking,
and lack of medical ethics knowledge); and (3) lack of resources (workforce shortage and lack of
medical equipment).
CONCLUSION: The results of this study suggest that health-care providers such as doctors and
nurses are unintentionally forced to provide discriminatory care on some occasions. Knowing and
managing these unwanted factors can partly counteract unintentional discrimination. Thus, preventing
the factors that lead to superiors’ pressures and occupational forces and improving the medical ethics
knowledge should be considered by health-care managers.


  1. Nguyen TT, Vable AM, Glymour MM, Nuru‑Jeter A. Trends for
    reported discrimination in health care in a national sample of older
    adults with chronic conditions. J Gen Intern Med 2018;33:291‑7.
    2. Whitaker KM, Everson‑Rose SA, Pankow JS, Rodriguez CJ,
    Lewis TT, Kershaw KN, et al. Experiences of discrimination
    and incident type 2 diabetes mellitus: The multi‑ethnic study of
    atherosclerosis (MESA). Am J Epidemiol 2017;186:445‑55.
    3. Abramson CM, Hashemi M, Sánchez‑Jankowski M. Perceived
    discrimination in U.S. healthcare: Charting the effects of key
    social characteristics within and across racial groups. Prev Med
    Rep 2015;2:615‑21.
    4. Versey HS, Curtin N. The differential impact of discrimination on
    health among Black and White women. Soc Sci Res 2016;57:99‑115.
    5. Parker LJ, Hunte H, Ohmit A. Discrimination in health care:
    Correlates of health care discrimination among black males. Am
    J Mens Health 2017;11:999‑1007.
    6. Brondolo E, Brady Ver Halen N, Pencille M, Beatty D, ContradaRJ.
    Coping with racism: A selective review of the literature
    and a theoretical and methodological critique. J Behav Med
    7. KaganSH. Ageism in cancer care. Semin Oncol Nurs 2008;24:246‑53.
    8. Perreira KM, Telles EE. The color of health: Skin color, ethnoracial
    classification, and discrimination in the health of Latin Americans.
    Soc Sci Med 2014;116:241‑50.
    9. Barber C. Disability discrimination in healthcare services and
    employment. Nurs Stand 2015;30:40‑5.
    10. Ginsburg OM. Breast and cervical cancer control in low and
    middle‑income countries: Human rights meet sound health
    policy. J Cancer Policy 2013;1:e35‑41.
    11. Piette JD, Bibbins‑Domingo K, Schillinger D. Health care
    discrimination, processes of care, and diabetes patients’ health
    status. Patient Educ Couns 2006;60:41‑8.
    12. van den Heuvel WJ, van Santvoort MM. Experienced
    discrimination amongst European old citizens. Eur J Ageing
    13. Rodríguez‑Álvarez E, González‑Rábago Y, Borrell LN,
    Lanborena N. Perceived discrimination and self‑rated health in
    the immigrant population of the Basque Country, Spain. Gac Sanit
    14. Sweiry DW. Attitudes to Age in Britain 2010/11. In: House
    Research no 7. London: Department for Work and Pensions; 2012.
    15. Fernandez‑Ballesteros R, Olmos R, Santacreu M, Bustillos A,
    Molina MA. The role of perceived discrimination on active aging.
    Arch Gerontol Geriatr 2017;71:14‑20.
    16. Wofford N, Defever AM, Chopik WJ. The vicarious effects of
    discrimination: How partner experiences of discrimination affect
    individual health. Soc Psychol Personal Sci 2019;10:121‑30.
    17. Board UP, editor. Zero Discrimination in Health Care Settings.
    Geneva, Switzerland: 2017.
    18. Nivaldo Linares‑Péreza OL. Health equity: Conceptual models,
    essential aspects and the perspective of collective health. Soc Med
    19. Haydt SM. Politics and professions: Interdisciplinary team models
    and their implications for health equity in Ontario. Int J Health
    Serv 2018;48:302‑27.
    20. Curtis LJ, MacMinn WJ. Health care utilization in Canada:
    Twenty‑five years of evidence. Canadian Public Policy
    21. Campesino M, Saenz DS, Choi M, Krouse RS. Perceived
    discrimination and ethnic identity among breast cancer survivors.
    Oncol Nurs Forum 2012;39:E91‑100.
    22. Etieyibo E, Omiegbe O. Religion, culture, and discrimination
    against persons with disabilities in Nigeria. Afr J Disabil
    23. Yasui M, Dishion TJ, Stormshak E, Ball A. Socialization of culture
    and coping with discrimination among American Indian families:
    Examining cultural correlates of youth outcomes. J Soc Social
    Work Res 2015;6:317‑41.
    24. Martin SS, Trask J, Peterson T, Martin BC, Baldwin J, Knapp M.
    Influence of culture and discrimination on care‑seeking behavior
    of elderly African Americans: A qualitative study. Soc Work
    Public Health 2010;25:311‑26.
    25. Shepherd SM, Willis‑Esqueda C, Paradies Y, Sivasubramaniam D,
    Sherwood J, Brockie T. Racial and cultural minority experiences
    and perceptions of health care provision in a mid‑western region.
    Int J Equity Health 2018;17:33.
    26. Hsieh HF, Shannon SE. Three approaches to qualitative content
    analysis. Qual Health Res 2005;15:1277‑88.
    27. Graneheim UH, Lundman B. Qualitative content analysis in
    nursing research: Concepts, procedures and measures to achieve
    trustworthiness. Nurse Educ Today 2004;24:105‑12.
    28. Kligyte V, Connelly S, Thiel C, Devenport L. The influence of
    anger, fear, and emotion regulation on ethical decision making.
    Hum Performance 2013;26:297‑326.
    29. Dehghani A, Mosalanejad L, Dehghan‑Nayeri N. Factors affecting
    professional ethics in nursing practice in Iran: A qualitative study.
    BMC Med Ethics 2015;16:61.
    30. Kaabomeir N, Mosavi M, mosavi S, Naami A. Assessing
    relationship between intra organizational factors that affect
    on nurses’ professional ethics behaviors. Q J Nurs Manage
    31. Habibzadeh H, Ahmadi F, Vanaki Z. Facilitators and Barriers to
    the Professionalization of Nursing in Iran. Int J Community Based
    Nurs Midwifery 2013;1:16‑25.
    32. Mahajan R, Aruldhas BW, Sharma M, Badyal DK, Singh T.
    Professionalism and ethics: A proposed curriculum for
    undergraduates. Int J Appl Basic Med Res 2016;6:157‑63.
  2. 33. Imran N, HaiderI, Jawaid M, Mazhar N. Health ethics education:
    Knowledge, attitudes and practice of healthcare ethics among
    interns and residents in Pakistan. J Postgrad Med Institute
    34. Bostani S. Strategies to promote professional ethics in nursing
    education system. Dev Strategies Med Educ 2015;2:13‑22.
    35. Aacharya R, Shakya Y. Knowledge, attitude and practice of
    medical ethics among medical intern students in a Medical
    College in Kathmandu. Bangladesh J Bioethics 2016;6:1.
    36. Ludwick R, Silva MC. Errors, the nursing shortage and ethics:
    Survey results. Online J Issues Nurs 2003;8:9.
    37. Shamsi A, Peyravi H. Nursing shortage, a different challenge in
    Iran: A systematic review. Med J Islam Repub Iran 2020;34:8.
    38. Yun H, Jie S, Anli J. Nursing shortage in China: State, causes, and
    strategy. Nurs Outlook 2010;58:122‑8.
    39. Borhani F, Abbaszadeh A, Mohamadi E, Ghasemi E,
    Hoseinabad‑Farahani MJ. Moral sensitivity and moral distress
    in Iranian critical care nurses. Nurs Ethics 2017;24:474‑82.